Free Motion for Leave to Proceed in forma pauperis - District Court of Delaware - Delaware

p Case 1 :07-cv—00505-SLR Document 1 Filed 08/17/2007 Page 1 of 2 · l
` AO 140 (Rev. 11]/U5) I
DELAWARE Bev. QUE! ` ‘ .
3%% , gs UNITED STATES DISTRICT COURT
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at iii DISTRICT OF DELAWARE
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y Plaintiff APPLICATION TO PROCEED
_ V. _ WITHOUT PREPAYMENT OF
Q t Qc. Qu .3},1 asa MD. { CMS) FEES Ama Arrmavrr
Defendant(s) . C, T —- 5 .
CASE NUMBER:
I, KQV A /3 · af declare that I am the (check appropriategox)
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° Petitioner/Plaintiff/Movant ° ° Other E
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in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to tire re§§§%Qg
sought in the complaint/petition/motion.
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In support of this application, I answer the folloisifxig/uestions under penalty of perjury: Q Z2
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l. Are you currently incarcerated? ° es ° No (If "No" go to Question 2)
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If "YES" state the place of your incarceration iUta}iI-jd l;`>t;g ii; Ci}{n"1Z.Q»ii0+Qt§.i

Inmate Identification Number (Required); Q U 5 [ I
Are you employed at theinstitution? O Do you receive any payment from the institution? U `
Attach a ledger sheet Qorn the institution of your incarceration showing at least the past sb: months '
- transactions l`
2. Are you currently employed? ° ° Yes ° l’{
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the a.mount of your take-home
l salary orlwages and pay period and the nam’e_and address of your last employer.
J/05 ~ Ll!/o?> [·h.trw¤¤~·» Lie. Mlaqtlel, Dt: @$50 ole.
3. Ln the pa t 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · • Yes » a 4, I
b. Rent payments, interestor dividends • · Yes • . ’
0. Pensions, annuities or life insurance payments · • Yes *"
d. Disability or workers compensation payments • • Yes ·· • `
e. Gifts or inheritances • • Y ·_ No
f. Any other sources ‘ Yes • • No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.
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Case 1 :07-cv—00505-SLR Document 1 Filed 08/17/2007 Page 2 of 2 ..
V AO 240 Reverse [Rev.`1D/D3) .
DEl..J\.WAREiEev, 4/U5! I .
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I 4. Do you have any cash or checking or savings accounts? • · Yes wtf
If “Yes" state the total amount S ’
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? i J
• • Yes •° o
If "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
Al o tl F
o I declare under penalty of perjury that the above information is true and correct. I
3 . ¤~ _'__ ..
"' ’· ‘1·vt i,—
DATE - SIGNATURE OF A " *' ANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit
stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
ofiicer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1 :07—cv—00505-SLR Document 1-2 Filed 08/17/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
OB/1D/07 11:16
ST 007 / OPR SJW F., .__ A ___`
U { AJ
SEI : 302981
Resident Name : APGAR, KEVIN
Time Frame : 02/01/2007 14:34 - 08/10/2007 11:16
Date Time Type ST DPR Receipt # Amount Balance
02/05/2007 09:30 Add 4 gmw D63035 40.00 50.76
02/06/2007 08:19 Order 2 WLH 13153980 8.89 41.87
02/13/2007 08:36 Order 2 DDT B155013 30.68 11.19
02/14/2007 08:39 Credit 3 WLH C18058 6.25 17.44
02/14/2007 08:39 Order 3 WLH C18059 3.25 14.19
02/20/2007 10:15 Order 2 DDT B156295 14.15 0.04
02/27/2007 09:28 Add 8 bef H28698 10.00 10.04
02/28/2007 12:43 Rec Payment 6 kjg F26207 4.00 6.04
03/06/2007 09:40 Order 2 DDT B158150 6.01 0.03
03/06/2007 12:09 Add 4 gmw D64893 30.00 30.03
03/12/2007 11:45 Add 4 J D65291 10.00 40.03
03/12/2007 15:35 Rec Payment 10 bsp J9004 1.00 39.03
Y 03/13/2007 09:39 Order 2 DDT E159147 25.80 13.23
03/20/2007 06:29 Order 2 DDT B160222 11.84 1.39
03/27/2007 06:10 Order 2 DDT B161148 1.30 0.09
03/29/2007 11:23 Add 4 CAR D66265 10.00 10.09
03/30/2007 12:42 Add 4 gmw D66372 12.00 22.09
04/03/2007 06:31 Order 2 DDT E161975 21.24 0.85
04/05/2007 12:57 Add 4 J D66729 20.00 20.85
04/10/2007 10:06 Order 2 AFC B163122 19.75 1.10
04/17/2007 06:32 Order 2 AFC B164139 1.04 0.06
04/18/2007 12:07 Add 4 CAR D67459 25.00 25.06
04/19/2007 11:10 Add 4 gmw D67489 25.00 50.06
04/24/2007 07:51 Order 2 DDT B165123 24.99 25.07
05/01/2007 09:13 Order 2 DDT B166159 21.01 4.06
05/03/2007 14:47 Rec Payment 10 bsp J9747 1.00 3.06
05/07/2007 12:18 Add 4 CAR D68496 20.00 23.06
05/08/2007 08:24 Order 2 DDT B167054 3.25 19.81
05/08/2007 08:38 Add 8 GLD H30442 20.00 39.81
05/15/2007 07:38 Order 2 DDT B168017 34.74 5.07
05/16/2007 08:46 Order 3 WLH C19620 0.20 4.87
05/17/2007 09:01 Add 4 gmw D69055 20.00 24.87
05/22/2007 09:10 Order 2 DDT B169030 22.37 2.50
05/23/2007 09:30 Credit 3 WLH C198'?7 0.80 3.30
05/29/2007 08:27 Order 2 DDT 13170029 3.25 0.05
05/29/2007 09:24 Add 8 GLD H30966 10.00 10.05
06/04/2007 12:24 Add 4 CAR D70010 20.00 30.05
06/05/2007 08:25 Order 2 DDT B170846 17.36 12.69
06/12/2007 08:46 Order 2 DDT B171821 5.93 6.76
06/14/2007 09:51 Rec Payment 7 SJW G11631 6.00 0.76
06/18/2007 09:09 Add 4 CAR D70746 20.00 20.76
06/19/2007 08:26 Order 2 DDT B172898 5.34 15.42
06/19/2007 10:08 Rec Payment 7 SJW G11707 4.00 11.42
06/26/2007 12:39 Order 2 DDT B173782 11.04 0.38
07/03/2007 06:51 Order 2 DDT B1'?4603 0.26 0.12
07/04/2007 09:42 Credit 3 WLH C20826 0.26 0.38
07/06/200'7 09:17 Add 6 wmd F302'79 20.00 20.38
07/10/2007 06:48 Order 2 DDT B175647 17.28 3.10
07/16/2007 12:13 Order 2 DDT B176449 2.99 0.11
07/18/2007 11:03 Add 4 SEA D72372 20.00 20.11
07/23/2007 08:59 Add 4 gmw D72554 15.00 35.11
07/23/2007 12:39 Order 2 DDT B177508 12.36 22.75
07/31/2007 06:55 Order 2 DDT B178315 15.02 7.73
08/O1/2007 15:19 Rec Payment 10 bsp J11275 2.50 5.23
08/06/2007 11:36 Add 4 gmw D73356 40.00 45.23 _
08/07/2007 09:15 Order 2 WLH E179317 17.92 27.31
08/09/2007 09:27 Add 8 bef H32617 20.00 47.31

Case 1:07-cv-00505-SLR

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Case 1:07-cv-00505-SLR

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Case 1:07-cv-00505-SLR

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